Heart failure is a condition in which the heart is unable to pump blood at the rate needed to fulfil the body’s metabolic needs, or only at the cost of high filling pressures. It results from functional or structural heart disorders decreasing the heart’s ability to fill or pump, and thus may have several causes, e.g. myocardial infarction, valvular disease, hypertension and atrial fibrillation. Heart failure (HF) is a clinical syndrome, not a single diagnosis. Identification of the underlying cardiac dysfunction is mandatory in the diagnosis of HF, since this will determine subsequent treatment.
Cardinal symptoms of HF are breathlessness, ankle swelling and fatigue. Symptoms increase during exacerbations. Signs at physical examination may be elevated jugular venous pressure, pulmonary crackles and peripheral oedema. Heart failure may become symptomatic at rest and / or during exercise.
Additional examination is indicated if heart failure is suspected, based on history and physical examination. A chest X-ray may help to differentiate from pulmonological causes for dyspnoea, such as showing cardiomegaly or pleural effusion. A (highly) elevated value of natriuretic peptide (BNP or NT-proBNP) makes HF (very) likely. An electrocardiogram (ECG) is advised when HF is suspected. A normal ECG makes HF unlikely, but an abnormal ECG does not yet demonstrate HF. Atrial fibrillation or a paced rhythm on the ECG increase the likelihood of the presence of HF. When HF is suspected and elevated (NT-pro) BNP and / or ECG abnormalities are present, echocardiography is indicated. The diagnosis of heart failure is normally made by the cardiologist, although in consultation with frail or elderly patients, referral to the cardiologist is sometimes omitted.
Cardiologists classify HF in three subgroups according to the left ventricle ejection fraction, which is generally assessed by echocardiography: heart failure with preserved ejection fraction (HFpEF), with mildly reduced ejection fraction (HFmrEF) and with reduced ejection fraction (HFrEF).
Treatment with medication is generally started by the cardiologist and often reduces the symptoms of HF. It can also prevent exacerbations and reduce mortality from heart failure. Daily medication is prescribed and dosed stepwise and includes renin-angiotensin system blockers (e.g. ACE-inhibitors) and diuretics when signs of fluid retention are present. Betablockers may be added in stable patients. Medication is normally needed life-long. Patients may be advised to take extra diuretics when fluid retention increases (ankle edema, weight gain). In the continuation of the treatment, GPs often contribute. Acute decompensations require prompt management.